By T. Gunock. Southern Virginia University. 2018.

Similarly purchase carafate 1000 mg amex, physical activity levels were not different between Pima Indian and Caucasian children (Salbe et al generic 1000mg carafate with mastercard. Thus generic 1000 mg carafate amex, there are currently insufficient data to define specific differences in energy requirements between different racial groups and more research is needed in this area. The question of whether normal variations in ambient temperature influence energy requirements is therefore complex. Ambient temperature effects are probably only significant when there is prolonged exposure to substantial cold or heat. The energy cost of work was judged to be 5 percent greater in a cold environment as com- pared to a warm environment (Consolazio et al. There can also be an additional energy cost (2 to 5 percent) of both the increased weight of clothing worn and the hobbling effect of that clothing in cold weather compared with clothing worn in warm weather (Consolazio et al. In addition, temperatures low enough to induce shivering or increased muscular activity will increase energy needs because of the increase in mechanical work (Timmons et al. More recent work also suggests that the recognized increase in energy expenditure in markedly cold cli- mates may be greater in physically active individuals than in sedentary ones (Armstrong, 1998). There is an increase in the energy expenditure of standard tasks when ambient temperatures are very high (Consolazio et al. However, this increase in energy expenditure may be attenuated by continued expo- sure. Garby and colleagues (1990) reported that the extra energy expendi- ture for 2 hours of light activity at 34°C fell progressively a total of 3 to 8 percent with acclimatization over 8 days of the study compared with activity at 20°C to 24°C. More recent studies have reported a significant effect of variations in ambient temperature within the usual range on energy requirements. Lean and colleagues (1988) reported a 4 percent increase in the sleeping metabolic rate of women at an ambient tempera- ture of 22°C compared with 28°C. Instead, the effect of ambient temperature appears to be confined to the period of time during which the ambient temperature is altered. Nevertheless, the energy expenditure response to cold temperatures may be enhanced with previous acclimatization by pro- longed exposure to a cool environment (Kashiwazaki et al. Since most of the recent data has been collected in women, further research in this area is needed. There was also no significant differ- ence in season-related values for physical activity in free-living adult Dutch women, but in contrast to the values reported above for soldiers, the values tended to be higher in summer than in winter (van Staveren et al. For this reason, no specific allowance is made for ambient temperature in the requirements for energy. Altitude Hypoxia increases glucose utilization whether measurements are made on isolated muscle tissue (Cartee et al. Adaptation and Accommodation There are two key differences between nutritional adaptation and accommodation (Waterlow, 1999). First, while adaptation implies mainte- nance of essentially unchanged functional capacity in spite of some alter- ation in steady-state conditions, accommodation allows maintenance of adequate functional capacity under altered steady-state conditions. Second, whereas accommodation involves relatively short-term adjustments, such as the responses needed to maintain homeostasis, adaptation involves changes in body composition that occur over a more extended period of time. Adaptation The term adaptation describes the normal physiological responses of humans to different environmental conditions. A good example of adapta- tion is the increase in hemoglobin concentration that occurs when indi- viduals live at high altitudes (Leon-Velarde et al. Changes in energy intake or in energy expenditure trigger metabolic and behavioral responses aimed at restoring energy balance in adults. These responses involve the endocrine system, the central nervous system, and the body energy stores. When effective, these regulatory mechanisms result in the maintenance of a stable body weight (Jequier and Tappy, 1999). Otherwise, individuals with higher efficiency would require less energy for equal energy expenditure than persons with lower efficiency. The experimental data supports the notion that differ- ences in efficiency of energy utilization among healthy individuals living under similar conditions fluctuate within a narrow range (James et al. Body weight can be remarkably stable in many healthy adults, demon- strating the human potential for maintaining energy balance and stable body composition in spite of conditions that have promoted the recent secular trends in increasing body weights. Maintenance of stable body weight and composition are affected by genetic factors, energy intake, and diet composition, as well as by other environmental factors (Hill and Peters, 1998). Environmental conditions favoring high energy consump- tion and low physical activity can overwhelm these mechanisms and lead to positive energy balance, resulting in body fat accumulation and weight gain until another state of weight maintenance becomes established. Thus, weight gain and obesity can be seen as a form of adaptation that brings about a new steady state (Astrup et al. A more practical defini- tion, applied to the study of energy requirements, would be the ability to compensate for changes in energy (energy intake, expenditure, or bal- ance) without any discernible detriment to health. Although the concept applies both to increases and decreases in energy intake or energy expenditure, a focus of controversy has been its application to the definition of energy needs in poor areas of the world. In studies that specifically attempted to assess whether some adaptive mecha- nism may permit those populations to subsist with lower than predicted energy intakes, no reduction in weight-adjusted basal metabolic rates could be detected (Soares et al. Reports on the ethnic and gender differences in energy efficiency have yielded conflicting results, but the overall contributions such differences can make toward the main- tenance of energy balance appears to be small (Soares et al. However, most overfeeding studies show that over- eating is accompanied by substantial weight gain, and likewise reduced energy intake induces weight loss (Saltzman and Roberts, 1995). Accommodation The term accommodation was proposed to characterize an adaptive response that allows survival but results in some more or less serious conse- quences on health or physiological function. By reducing growth rate, chil- dren are able to save energy and may subsist for prolonged periods of time on marginal energy intakes, though at the cost of eventually becoming stunted. This can result in reduced productivity of physical work or in decreased leisure physical activity, which in children is important for behavioral and mental development (Twisk, 2001). However, the measurements were obtained from men, women, and children whose ages, body weight, height, and physical activities varied over wide ranges, so they provide an appro- priate base to estimate energy expenditures and requirements at different life stages in relation to gender, body weight, height, age, and for different activity estimations. A few age groups are underrepresented in the data set and interpolations had to be performed in these cases. This data set, used to estimate the current energy recommendations, can be used to refine other existing communicated recommendations or guidelines developed by other orga- nizations and agencies. Subjects were required to be healthy, free-living, maintaining their body weight, and with measured heights and weights. Exclusion crite- ria included undernutrition, acute and chronic diseases, underfeeding and overfeeding protocols, and lifestyles involving uncommonly high levels of physical activity (e. There are 407 adults in the normative database (Appendix Table I-3), 169 men and 238 women. Among the men whose ethnicity was reported, there are 33 Caucasians, 7 African Americans, and 2 Asians, and among the women there are 94 Caucasians, 13 African Americans, 3 Asians, and 3 Hispanics. For the 100 adults for whom data were provided on occupation, the most com- monly reported types of occupations were offices workers, followed by teachers and students, scientists, medical workers, active occupations (e. The database for normal-weight children (n = 525) (Appendix Table I-2) includes 167 boys (73 Caucasians, 13 African Americans, 4 Hispanics, and 62 American Indians) and 358 girls (197 Caucasians 58 African Ameri- cans, 20 Hispanics, 10 Asians, and 60 American Indians); ethnicity was not provided for 15 boys and 13 girls. There were insuffi- cient data to address pregnancy and lactation in overweight and obese women.

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Figure 1 depicts early successes in specific types of cancer cheap carafate 1000 mg without a prescription, where genomics has already enabled pre-symptomatic diagnosis cheap carafate 1000 mg, personalized therapy and personalized drug dosages purchase 1000 mg carafate visa. Genomics enabled approach to specific cancers Pre-symptomatic or symptomatic Targeted therapy Pharmacogenomic gene test, risk, prediction testing for dosage Pre-symptomatic diagnosis Personalized therapy Personalized drug dosage e. These data provide a basis for diagnosis and, if possible, a determination of personalized treatment(s). However, the presence of mutations in these genes increases the lifetime “likelihood” of developing breast cancer and other cancers, such as ovarian cancer. Predisposition testing can also test for rarer gene disorders that manifest in adulthood (e. Pharmacogenomic testing enables an understanding of how an individual’s genetic variation for specific drug-metabolizing enzymes may affect the body’s response to the drug being administered (Epstein 2004; Johnson 2003). Using such profiles to adjust warfarin dosage can prevent complications of warfarin treatment. Most drugs produce a spectrum of responses in various people: from no effect in some, to a moderate effect in most, to an absolute cure in a few. Targeted therapy aims to identify those persons for whom a given drug is highly efficacious, and avoid giving the drug to those in whom it will have little or no effect. This not only provides a path to novel therapies, but also rehabilitates older drugs that have cured some people, but on average have had little effect or been overly toxic. The genomic approach toward drug-target isolation offers significant advantages over the tried and tested approaches that pharmaceutical companies have used. Such therapies are precise and hence possess high efficacy, but often only in a subset of individuals with a specific condition. For example, screening for and treating phenylketonuria provides net direct cost savings to society. In the case of imatinib, a first-line therapy for chronic myeloid leukemia, a six-year increased survival rate over interferon-alpha therapy has been noted, with a $43,100 per life-year saving (Reed et al. Prenatal genetic testing, genetic predisposition testing and pharmacogenomic testing are three categories of tests which are regularly being offered to healthcare consumers today. However, data from research studies detailing clinical outcomes based on pharmacogenomic testing and the appropriate dosage of specific drugs remain sparse. Similarly, data on clinical outcomes associated with genetic and genomic interventions are more the exception than the norm (Scheuner et al. The business of genetics – examples of molecular diagnostic testing three companies offering molecular diagnostic testing 5 Genomic Health Inc offers a molecular based test – OncotypeDx, which analyzes the expression patterns of a panel of 21 genes and provides a likelihood of breast cancer recurrence in women with newly diagnosed early stage breast cancer. In addition, this test is also able to predict the benefits from certain types of chemotherapy. Thus, based on the results of this test, it is possible to screen for and differentiate women with a specific type of breast tumour who may not benefit from chemotherapy. Genzyme offers a comprehensive menu of genetic testing for single gene disorders e. Navigenics offers a Health Compass package which includes 24/7 access to genetic counsellors ongoing, secure, personalized updates for an entire year, adding new condition predispositions, new markers, new clinical therapies, other wellness strategies, and easy-to-use, relevant health information. Gefitinib is an anti-cancer drug for patients with recurrent non-small-cell lung cancer who have specific mutations within a specific gene. Through genetic testing, candidates for gefitinib (instead of chemotherapy) can be identified. Imatinib is a drug therapy that affects the molecular cause of chronic myeloid leukemia. Imatinib acts by specifically interfering with an abnormal protein, thereby preventing it from overpro- ducing white blood cells. Genomic medicine is expected to have the following profound impacts on the future of healthcare: • Transformation of healthcare delivery – genomic medicine is expected to allow the delivery of personalized care by professionals who understand the medical, ethical, legal and social implications of genomics information when applied to healthcare consumers. Healthcare delivery in such cases includes the spectrum from molecular Electronic Healthcare, Vol. The likely scenario within a decade is the common availability of whole-genome sequencing with a pharmacogenomic profile that provides a comprehensive risk assessment for various genetic and multi-factorial conditions and a list of personal- ized drugs with personalized dosages based on an individual’s genotype. This closely resembles Moore’s law, which applies to increased computing power and decreased costs. Genomics holds the promise of realizing value from enormous past investments in drug candidates that were eliminated due to person-specific toxicities or lack of efficacy. What are the Key enablers For GenomIcs to InteGrate In the delIvery oF healthcare? The use of such information is predicated upon individuals understanding both the short- and long-term impacts of such informa- tion. Genomic literacy is a crucial aspect in the dissemination and integration of such information in healthcare. However, genomic information can be complex and hard for an end consumer to interpret. For example, the fundamental difference between a screening test and a diagnostic test at the consumer level is a concept that can be diffi- cult to understand. Thus, even the most well-informed, “Google-centric” consumers can have difficulty in understanding and interpreting genetic results and the impact of such information on their lives. Apart from finding a lack of sufficient outcomes-based data, they found that health- care workers, while enthusiastic about genetic testing, often did not have the time, skill or knowledge to refer at-risk persons to specialists for genetic tests and/or consulta- tion. In general, healthcare workers were felt to be under-prepared to deal with genetic and genomic data in their practices, pointing to the attention that needs to be paid to genomic literacy. Currently, genomic information is largely provided by trained geneticists (physicians with specialized genetics training) and genetic counsellors (master’s-degree-trained certified professionals). Given the future impact of genomics technologies on health- care, physicians and other professionals are unlikely to have the necessary genomics 7 knowledge to truly do justice to the available technology. Jane is pregnant and arrives at a genetic clinic for prenatal genetic counselling. This leads to multiple counselling sessions with both Jane and her husband before the couple make their decision. This scenario requires professionals to have both scientific and psycho-social expertise in communicating and helping people to arrive at an informed decision. The sidebar gives a present-day scenario depicting some of the complexities involving educational and training resources that genomics information entails. With a growing supply and demand for genomics services, the importance of qualified professionals who can do justice to understanding and communicating sensitive infor- mation to individuals seeking such testing will be key. The role of the family physician will change, as these professionals will have to take an increasing responsibility for providing genomics information. Innovative educational methods, a telemedicine- type service with a genetics component (telegenetics) and portals that allow people to explore their genetic data will likely be demanded by consumers. Through Informed, Aetna, a large insurance company, is now offering its members confidential telephone and web-based cancer genetic counselling services as part of their health benefits. Similarly, consumer genomics companies are offering portal-based services to consumers interested in tracking their genomics information. Given the likelihood of a $1,000 personal genome test, and the advent of genomics companies offering direct-to-consumer genetic tests, the importance of the privacy and security of genomic information 8 cannot be understated.

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Evolutionists carafate 1000mg generic, on the other hand order 1000mg carafate fast delivery, view populations as embedded in ecological communities that comprise a myriad of interrelated and interacting species buy discount carafate 1000mg on line, all of which are subject to natural selection and are therefore coevolving. Physicians certainly recognize environmental causes of disease, espe- cially infectious diseases and diseases due to environmental toxins. Nonetheless, medical research has focused on the inner workings of human beings, on the physiological and pathophysiological mechanisms that promote health or lead to disease. Medicine is concerned with what Claude Bernard (1957) termed the “internal environment,” the blood and extracellular fluids that provide the immediate environment in which our cells and organs function. In this view, health involves the maintenance of constant, or nearly constant, conditions in the internal environment—conditions that enable cells and organs to function prop- spring 2013 • volume 56, number 2 177 Robert L. Perlman erly—while diseases are manifest by deviations from these “normal” conditions. Evolutionary biologists appreciate that the physiological mechanisms that main- tain homeostasis are adaptations that enhance fitness, but they are more inter- ested in studying the interactions of organisms with their external environments, because it is these ecological interactions that shape the struggle for existence and natural selection. Appreciation of the physiological functions and patho- physiological effects of the human microbiome, the communities of microor- ganisms that inhabit our skin, intestines, and other body cavities, has led to the recognition that humans are ecological communities. Indeed, study of the microbiome is a growing area of research in which the interests of physicians and evolutionists are converging (Turnbaugh et al. Finally, medicine and evolutionary biology have different ways of thinking about variation. Physicians distinguish between “normal” values of traits, values that are associ- ated with good health or that are common in the population, and “abnormal” values, values that are associated with an increased risk of disease. In a medical context, this distinction between normal and abnormal often makes good sense. Many deviations from normal values—elevated blood pressure, blood choles- terol, and body mass index, for example—are risk factors for diseases that may be prevented or postponed by medical interventions. Occasionally, however, extreme values of a trait—short stature, for example—may be labeled abnormal even if they do not have implications for health. Since the rise of the Human Genome Project, physicians are certainly aware of and concerned about genetic variations among their patients. But medicine is still influenced by an essential- ist view of biology that tends to view phenotypic variations as deviations from a normal, healthy, or ideal state. This medical understanding of variation differs from that of evolutionary biologists, who view variation as a fundamental prop- erty of biological populations. Not only is variation abundant in nature, it pro- vides the substrate for evolution by natural selection; if there weren’t heritable variations among individuals, populations couldn’t evolve. The values of specific traits among individuals typically exhibit a distribution, frequently a normal or lognormal distribution, that is associated with variations in fitness. Often, but not always, the median or mean value of a trait is maintained by natural selection be- cause it is associated with maximal fitness. Only rarely if ever are there sharp cut- offs that separate health from disease or distinguish different levels of fitness. Historically, then, medicine and evolutionary biology have been concerned with different biological problems and have developed different approaches to study their areas of interest. It is not surprising that they have developed as sep- arate, unrelated disciplines. But physicians and nonmedical biologists have begun to realize that there is much to be gained by integrating these disciplines. Evo- lutionary medicine recognizes that these different perspectives are complemen- tary, and that integrating them will give a richer understanding of health and disease. Understanding evolutionary processes helps to explain our evolved vul- 178 Perspectives in Biology and Medicine Evolution and Medicine nerabilities or susceptibilities to disease and our current burden of disease. Con- versely, since disease has served as an important selection factor in evolution (Haldane 1949a), knowledge of the present patterns of disease gives insights into our evolutionary history. Analysis of the evolutionary causes of diseases may lead to novel strategies to prevent, postpone, or ameliorate them. Understanding both the proximate and ultimate causes of diseases will provide a richer understand- ing of disease. Finally, evolutionary explanations of disease are important because patients often want to know why they have the diseases they have. In the absence of evolutionary explanations, they may fall back on unhelpful folk beliefs, such as the idea that their diseases are punishment for sinful behavior (Bynum 2008). Why Our Evolutionary Heritage Has Left Us Vulnerable to Disease Many diseases cause premature death (death before the end of the reproductive and child-raising periods) or reduced fertility. But most diseases do not affect all members of a population or do not affect everyone to the same degree. Rather, individuals exhibit variation in resistance or response to diseases, just as they exhibit variation in virtually all other traits. At least some of this variation is due to genetic or heritable variation in the population. Heritable variations in resis- tance to these diseases represent variations in fitness; individuals who survive and remain fertile in the face of a disease will on average produce and raise more children than will people who die from or become infertile as a result of the dis- ease. As a disease spreads through a population, natural selection will increase the frequency of alleles that are associated with resistance to it. The alleles associated with resistance to malaria are classic examples of this process. Despite selection for disease resistance throughout our evolutionary history, however, natural selection has clearly not eliminated disease. Evolutionary med- icine helps us understand the limits as well as the power of natural selection in shaping human biology and the reasons—the ultimate causes—for our contin- ued vulnerability or susceptibility to disease. Broadly speaking, there are several important limits to natural selection that contribute to the persistence of disease (Nesse 2005; Perlman 2005). First, there are limitations intrinsic to the process of evolution by natural selection itself. Diseases that cause premature death or reduced fertility will select for and increase the frequency of alleles that are associated with disease resistance. New alleles can enter populations either by mutation or by gene flow from other populations of the same species. Once these alleles enter a popula- tion, their fate is determined by genetic drift (changes in allele frequency due to random sampling in the transmission of alleles from one generation to the next) as well as by natural selection. These other evolutionary processes may counter- act the effects of selection by introducing or increasing the frequency of alleles spring 2013 • volume 56, number 2 179 Robert L. For these and other genetic reasons, ben- eficial alleles—specifically, alleles associated with disease resistance or a decreased risk of disease—may not spread or become fixed in a population. Natural selection increases the frequency of traits that enhance reproductive fitness.

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Teaching activities comprise of both theoretical and clinical learning which will be delivered via seminars carafate 1000mg line, ward rounds cheap carafate 1000 mg without a prescription, clinic sessions safe carafate 1000 mg, operating theatre, endoscopy sessions, problem solving and learning and case presentation. Students are expected to clerk and follow the patients’ progress under their care. Each student will be supervised by lecturer, who will monitor his/her progress via clinical attendance, logbook and supervisor’s report. Students will be assessed through continuous assessment and end of course examinations. The aim of the course is to enable the students to understand common problems in internal medicine. Teaching activities comprise of both theoretical and clinical learning which will be delivered via 46 seminars, ward rounds, problem-solving learning, clinic sessions and case presentation. Students are expected to clerk and follow the patients’ progress under their care. Each student will be supervised by a lecturer, who will monitor his/her progress via clinical attendance, logbook and supervisor’s report. Students will be assessed through continuous assessment and end of course examinations. The aim of the course is to enable the students to understand and manage normal pregnancy, normal labour and puerperium and also common problems in Obstetrics and Gynaecology. The sense of professional etiquette in Obstetrics and Gynaecology will also be instilled into the students. The theoretical teaching will be delivered via student seminar whilst the clinical teaching will include the practice in the Clinical Skills Laboratory, ward rounds or bed-side teachings, clinic sessions and case presentation. Students are expected to clerk and follow the management of all patients under their care. Each student will be supervised by a lecturer, List of text/reference books (a) Main references : 1. This course also allows students to propose and implement strategies that provide comprehensive care and treatment to the case / patient and family. This course will provide an initial exposure or simulation to students about the functions of family doctors in managing the health problems of patients List of text/reference books (a) Main references : 47 th 1. The aim of the course is to enable the students to understand common problems in Ortopedik. Teaching activities comprise of both theoretical and clinical learning which will be delivered via seminars, ward rounds, problem-solving learning, clinic sessions and case presentation. Students are expected to clerk and follow the patients’ progress under their care. Each student will be supervised by a lecturer, who will monitor his/her progress List of text/reference books (a) Main references : nd 1. The aim of the course is to enable the students to understand common problems in psychiatry. Teaching activities comprise of both theoretical and clinical learning which will be delivered via lectures, audiovisual sessions, problem-solving learning, clinic sessions and case presentation. Each student will be supervised by a lecturer, who will monitor his/her progress via clinical attendance, logbook and supervisor’s report. Students will be assessed through continuous assessment and end of course examinations. This course aims to expose students to the primary health care and relevant ethical issues. Students will be trained to identify patients who need further care and referrals. Theory will be taught in the form of lectures and seminars, and clinical learning will be applied through laboratory training in clinical skills, role-play, clinic and problem-solving sessions. The aim of the course is to enable the students to understand common problems in ophthalmology. Teaching activities comprise of both theoretical and clinical learning which will be delivered via tutorials, seminars, ward rounds, clinic and operation theater sessions, problem- 49 solving learning and community service Students will be assessed through continuous assessment and end of course examinations. The aim of the course is to enable the students to understand common problems in Otorhinolaryngology. Teaching activities comprise of both theoretical and clinical learning which will be delivered via seminars, ward rounds, problem-solving learning, clinic and operation theater sessions and case presentation. The students are given the flexibility to choose their clinical placement either in or outside the country. Through this course, students will be exposed to the comprehensive management of patients while being supervised by field supervisors determined by the authority of the selected hospitals. 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The aim of the course is to enable the students to understand and manage problems in Paediatrics. The sense of team spirit and professional etiquette in paediatrics will 51 also be instilled into the students. The learning will be delivered via seminars, tutorials, practice in the ward rounds, bedside teachings, clinic sessions and case presentation. Students are expected to clerk and follow the management of all patients under their care. Each student will be given a supervisor, who will monitor his/her progress via clinical attendance, logbook and supervisor’s report. Students will be assessed through continuous assessment and end of course assessment. The main objectives of this posting include ability to gain clinical skills (diagnosis and management) in managing surgical problems. In this posting, we expect the student to gain effective communication and professional with patient, colleagues and public by using clinical cases as continuous learning process. Theoretical teaching includes presentations of topics common to surgical patients in tutorials. The students are also expected to clerk their own patients in the ward and follow-up in their management and progress.